Bladder Cancer

Bladder Cancers are primarily Transitional Cell Cancers. Transitional cells are the type of cell that lines the inside of the bladder, the ureters and the inside of the collecting system of the kidney. Transitional cell cancers can develop in any of these areas, but are most often found in the bladder. These tumors usually present with gross (you can see the blood) painless hematuria. The blood may be minimal or very transient to very severe with clots. Diagnosis is usually made by cystoscopy, looking in the bladder with a small scope made for that purpose. Other tools for diagnosis and management are urine cytology, and various types of x-rays or ultrasounds.

Bladder Cancer is most common in men and tends to be more frequent with age. It is clearly associated with smoking and second hand smoke. There are other associations as well.

The majority of these tumors are low grade papillary tumors. Visually they look like white to pink broccoli. They often can be managed by removing the tumor through a scope. We increasingly use bladder treatments afterward to reduce the number and frequency of recurrences. Higher grade more aggressive tumors are serious and dangerous cancers. Determination of the tumor type, grade and stage are made by biopsy and removal of the tumor and by imaging studies. The proper approach to the tumor can then be determined. They usually require removal of the bladder and reconstruction of a new bladder. Surgical options for more advanced tumors can include ileal conduits, continent urinary reservoirs and neobladders. Chemo therapy is often used along with surgery in these cases. Radiation therapy is used much less often with this particular type of cancer.

Enlarged Prostate – BPH

The prostate in normally a golf ball sized gland that sits in the pelvis underneath the bladder. The gland makes most of the white fluid that is ejaculated when a man has an orgasm during sex. The tube that drains the bladder (urethra) passes through the middle of the gland and out through the penis. When the gland enlarges, as often occurs with age, the urethra can get compressed like squeezing a straw. The prostate can enlarge compressing the passage through it or enlarge upward into the bladder. This makes it difficult to empty the bladder and produces symptoms like a slow or prolonged stream, getting up at night (nocturia), straining, frequent and urgent to void. Other symptoms can be bloody urine (hematuria), overflow incontinence, incompletely emptying the bladder and ultimately acute urinary retention where the bladder fills and one is unable to urinate at all.

Prostatic enlargement is a common condition affecting many men as they age. It is rare before age 40, and develops progressively with each decade. It affects well over half of men by the age of 70.

The cause of BPH is a matter of intense research. It is clearly hormone dependent. The male hormone testosterone produced in the testicles, is transformed into a stronger male hormone called dihydrotestosterone or DHT. This hormone is required to maintain an enlarged gland. However other factors including genetic and inflammation seem to be involved as well. Ratios of DHT the male hormone and a female hormone estrogen or estradiol may be part of the cause as well.

Urology Group of New Mexico uses a wide variety of methods to evaluate and diagnose enlarged prostate. The patients story, his signs and symptoms, are the beginning of the evaluation. This history includes the AUA Symptom Index which is a series of questions, standardized to determine the presence and severity of BPH. This test is included in our new patient paper work and will be sent to you when you make an appointment. It is also available at the American Urological Association (AUA) website, www.aua.org. PSA testing helps differentiate between BPH problems and the presence of prostate cancer. The well known DRE or digital rectal examination is useful to help determine the size of the gland, presence of infection or possibilities of prostate cancer. The lubricated and gloved finger can only examine the back side of the prostate, so we use transrectal prostate ultrasound examinations as a highly sensitive and reproducible method of determining prostate size. Other forms of testing include uroflowmetry to determine the flow rate at which one is able to empty the bladder. Uroflow testing along with urodynamic testing provide pressure/flow studies that determine the degree of obstruction. Lastly post-void residual testing, done with an ultrasonic bladder scanner determines the amount of urine remaining in the bladder after urination is completed. Normally, there is about an ounce or so left behind.

Hematuria

Hematuria means blood in the urine. There are two categories, gross hematuria and microscopic hematuria. Gross hematuria implies that one can see the blood in the urine……. from just looking dark to obvious thick blood and clots. Microscopic hematuria is blood detected by the doctor or lab under the microscope or by urine dipstick test. Another categorization of hematuria is the absence or presence of pain. Painless hematuria especially when gross is concerning for tumors. Hematuria with pain is more concerning for infections or stones.

At Urology group we try to identify the source of the blood as quickly as possible. Hematuria evaluations of course include a urine analysis, but also other tests including cultures to check for infection, x-rays, ultrasounds and CT scans to look for stones and tumors. Cystoscopy (looking in the bladder with specially designed telescopes) is often employed to look for tumors in the bladder. Other Urine tests sometimes utilized are cytology, Uro Vysion. We often find a reason for the blood and then will move on to treatment if that is warranted. Everyone has a few red blood cells in the urine. Urine dip sticks are developed to detect the “normal” amount and negative evaluations for hematuria are not infrequent.

We will endeavor to find the source of your hematuria as quickly as possible to put your mind to rest about this often concerning condition.

Holmium Laser

This precision device is used to break up bladder and kidney stones. A laser fiber is passed to the stone location. It is aimed at the stone just off the surface and the laser energy is then fired at the stone to fragment it into small pieces. These pieces are then passed naturally by the patient in most cases. This laser is used primarily for stones in the ureters, but is also used for bladder and kidney stones depending on the situation.

Impotence ED-Erectile Dysfunction

Impotence is a huge concern for many men, even younger ones. This problem effects self esteem, relationships and even reproductive abilities in some cases. Thanks to Viagra, Levitra and Cialis and the related advertising these problems have come out of secrecy and are much more approachable for many men. Still it takes a great deal of courage to come into the doctor and seek help for this problem.

Evaluation of this problem starts with a good history. Upon scheduling an appointment for this problem you will be sent a form asking about your sexual functioning as well as other health issues that may impact your performance. We also try to define the problem as some men are not totally clear on the factors that may be contributing to their poor performance.

Evaluation also consists of a physical examination and blood testing, including a male hormone profile, PSA and other relevant tests. It is helpful to bring copies of any recent lab testing to avoid redundant testing. In some cases we do penile ultrasound examinations to assess penile arterial inflow, venous leakage and Peyronnie’s plaques.

Treatment may be some of the oral meds mentioned above, vacuum pumps, injection therapy, or penile implants. All of these approaches have their place, depending on the patient, their specific issues, and personal preferences.

We give ED the serious consideration that it deserves and strive to make patients feel comfortable addressing this sensitive issue.

Incontinence

Urinary incontinence is a common problem in both men and women. It is seen frequently in children in both sexes. It is common in women during mid life and again in both sexes in later years. There are several types and causes. Our goal is to identify the type and cause of the leakage and then use whatever methods are required to resolve or manage the problem as expeditiously as possible.

Evaluation always begins with a good history of the problem. This includes not only issues related to the incontinence itself but also other medical conditions, dietary history, voiding habits and physical limitations. Physical examination including the abdomen, pelvis, rectum, vagina and prostate are often pertinent. Examination gives clues as to the physical abnormalities and tissue changes that may be contributing to the problem. In women, cystocele, pelvic prolapse or pelvic vault prolapse associated with bladder hypermobility are common especially after childbirth. Type I, Type II, and Type III stress incontinence are in part determined by physical examination and history.

Urinalysis is done to identify other conditions that may be causing or contributing to incontinence. Bacteria in the urine indicate an infection. Pyuria, the presence of pus or white blood cells in the urine can indicate infection or other inflammations. Glucosuria indicates too much sugar in the urine and probably in the blood stream. Occasionally, we diagnose cases of diabetes in this way. Hematuria, blood in the urine can indicate infections, stones, tumors and other problems in the urinary tract. Proteinuria, protein in the urine can indicate kidney disease and other conditions.

After the above evaluation, specialized testing can be used to further define issues that may impact the diagnosis and treatment of the incontinence condition. These tests are chosen individually given each patient’s complaints and situation.

Additional testing may include:

Cystoscopy – Special scopes are used to look inside the bladder to define anatomy and look for bladder wall changes (cystitis), inflammation, stones, and bladder cancer.

Post void Residual Volume (PVR) – We use a bladder scanner machine to look at the bladder with ultrasound, and in a noninvasive way determine the amount of urine remaining in the bladder after urination. This is a good way to determine incomplete voiding and urinary retention.

Urodynamic Testing – A newly acquired, state of the art, Mediscan urodynamic machine is often used in cases to determine how the bladder is functioning. Several tests may be involved from simple cystometry, to multichannel complex urodynamic testing. We use subtracted pressures to separate bladder (detrusor) pressures from abdominal pressures, leak point pressures and other parameters to assist in diagnosing and treating each patient’s condition.

Radiological Examinations - Sometimes ultrasound and x-ray examinations are useful in the evaluation of incontinence.

Treatment

Treatment is highly dependent on the cause and the results of the above examinations and testing.

Sometimes simply treating an unrecognized infection is all that is needed. Dietary modification, Kegel exercises, alteration of voiding habits can be helpful in some cases. Biofeedback and other pelvic floor exercises, sometimes using the assistance of physical therapy is available.

Treatment of prostate disorders, like enlarged prostate may resolve incontinence issues. This may be done with medications or surgery or other minimally invasive treatments like TUNA (PROSTIVA) done in the office.

Treatment of Neurogenic Bladders is often directed at managing incontinence and preserving the function of the kidneys.

Kidney Cancer

Kidney Cancers comprise about 35% of all adult cancers. They primarily occur in the 50 to 70 year age group, but it is not uncommon to see them in the 40’s. Men develop this disease about twice as often as women. Smokers double their risk of this condition. By far, most kidney cancers are renal cell cancers. These are cancers that develop from the lining of the tubules in the kidney.

Kidney cancers used to be discovered when patients noted blood in their urine or a mass in the abdomen. In the last few decades, they are commonly found during ultrasound or x-ray examinations for other reasons. Sometimes passing a kidney stone leads to the discovery of these tumors.

Treatment for Kidney cancers is usually surgical. Removal of the entire kidney was often required in the past. As more cancers have been found incidentally, they are sometimes smaller in size and can be treated with only removing part of the kidney (a partial nephrectomy) or by freezing the tumor. The exact approach to each tumor depends on its location, size and the anatomy of the kidney. Dr. Snoy is adept at laparoscopic surgery to remove these tumors.

Kidney Stone Evaluation and Prevention Programs

Kidney Stones are terribly painful and expensive events. They can damage the kidney and even prove fatal in rare circumstances. Surgical procedures, hospitals, lithotripsy and time away from work are all part of the costs.

Stone prevention is therefore one of our main goals. We try to find the cause of the stone formation in almost anyone who has had multiple stones, large stones or a difficult time treating their stone.

The key to prevention is a large urine output to keep the urine clear and dilute. In most adults we recommend a 2 quart a day urine output. You may need to drink 3 to 4 quarts of liquid a day to produce 2 quarts of urine per day.

A good dietary history will be taken. We will send off to the lab any stones passed or retrieved for a composition analysis. Please bring us any stones that you pass…yes retrieve it from the toilet! Finally we often do a metabolic evaluation consisting of a blood tests and 24 hour urine collections to see why stones form in your urine. Urine collections are often done with collection kits called Litholink or UroRisk. We will order these for you when indicated. Once collected, all of the above information is evaluated and a specific set of recommendations will be given to each patient.

The tough part about managing your kidney s tones is sticking to the recommendations…for the rest of your life. Once you have made a stone you have a 30 to 70 % chance of having another one in your lifetime. Remembering your kidney stone pain is a useful motivator.

Did you know..stones were mostly a male problem until the last 15 years, now women predominate.

Did you know… obesity is a strong risk factor for making stones.

Did you know…there are 4 different kinds of calcium over excretion form the kidneys.

Lithotripsy
ESWL (Extracorporeal Shockwave Lithotripsy)

Most stones located in the kidney or upper ureters are broken up by lithotripsy. The patient is positioned on a special table, given anesthesia, and then shockwaves from the machine are focused on the stone inside the kidney or ureters. The shock waves break the stones into small fragments that are then passed out through the urinary tract. Original versions of these machines had the patient placed in a bath of water to transmit the shockwaves. We use the newer versions of the machines where the bath has been downsized to a small water balloon placed against the patients back. The treatments usually take about an hour and are done as an outpatient.

No Scalpel Vasectomy

This is the vasectomy technique developed in China in the early ‘90s. The procedure is quick (usually 5 to 10 minutes) and utilizes only a tiny skin opening. I usually remove a small segment of vas, cauterize and clip the ends. A video discussion of the procedure is available on this web site. Pain is mild and usually treated with Tylenol or ibuprofen. We can arrange for pre vasectomy sedation and pain medicine if the patient feels he will need it. Occasionally we can opt for the procedure to be done under anesthesia in the hospital.

Peyronie’s Disease – Bent Penis

Peyronie's Disease (PD) is an abnormal build up of scar tissue along the shaft of the penis under the skin. It causes curvature of the penis and pain with erections. Symptoms vary and PD may present with penile shortening or impotence. The cause is unknown although there are a number of unproven theories. PD is not a cancer or malignancy.

PD is not contagious or dangerous to the man or his partner. It can have a major impact on sexual functioning and relationships and some men have a lot of distress and anxiety about the condition.

We have a lot of experience in managing this difficult problem. Medical treatments have been aimed at preventing or reducing scar formation. Oral medications that have been used are Vitamin E, colchicine, and Potaba. Recently pentoxyphylline has been felt to impact scar formation and is being used by some thought leaders.

Surgical treatments have been aimed at straightening the penis and sometimes removing the scar tissue as well. Nesbitt operations and occasionally graft placement at the scar site are done. In patients with impotence and PD a penile prosthesis placement is often a great approach. We evaluate each case with a detailed history, assess sexual functioning, and occasionally image the plaques with ultrasound. Treatment options are often patient driven with physician input.

Prostate Cancer

Prostate Cancer is the most common cancer in men and the second most common cause of cancer death in men. Possibly no other conditions causes more fear and expenditure of health care dollars in the field of urology. Thankfully medical personal have the PSA blood test to help screen and diagnose men with this condition even though it is very imperfect tool.

Prostate cancer is most commonly an issue for men in the 50’s, 60’s and 70’s. Diagnoses are usually accomplished by a Prostate Biopsy as discussed in another section. Fortunately most biopsies are negative, but if cancer is found it is graded by the Gleason grading system. Patients are seen in follow up for a detailed counseling session where we go over the biopsy results and create a profile of the patient’s specific situation and issues that might impact his treatment options and decisions. No two men are the same and each brings a specific set of issues to the table that need to be addressed.

Treatment options are many and will be driven by the issues discussed above. Some of the most common treatments are surgery to remove the prostate, radiation therapy to try to kill any cancer in the gland or sometimes hormonal therapy to slow down the progress of the disease. Chemotherapy is starting to be used early in the course of treatment as well. Increasingly men are seeing combinations of these treatments used to address the problem. I am an expert at diagnosing and managing prostate cancer with many years of experience

Prostatitis

Prostatitis means inflammation of the prostate. There are several different kinds of prostatitis based on the presence or absence of bacterial infection, inflammation in prostatic fluid, and the acute or chronic nature of the problem. In may take some time working with the patient to classify their type of prostatitis.

Prostatitis usually causes some of these symptoms: Low back pain, low abdominal pain, pain between the legs, ejaculatory pain, painful urination, tiredness, or weakness. Some men describe the feeling they are sitting on a golf or tennis ball. Severe cases are associated with fevers and chills or the inability to urinate.

Treatment often includes antibiotics and anti-inflammatory medications.

We work with our patients carefully to resolve symptoms, indentifying and classifying the problem to resolve the situation.

Some men with “chronic prostatitis� actually have a condition better termed as “chronic pelvic pain syndrome�.

PSA, Free and Total PSA, and PSA-3 Testing

PSA is a protein circulating in the blood given off by normal prostate cells as well as prostate cancer cells. This blood test is often used as a screening test to look for men who may have prostate cancer. While it is far from perfect it determining who has and does not have prostate cancer, it is an extremely useful tool. Interpretation of results has to include assessing the patient’s age, gland size and a variety of other factors. It is extremely useful to have a PSA history when assessing the implications of a PSA number. I therefore ask patients to gather all of their old PSA test results so that we can look at their current number in light of what it has been in the past.

% Free and Total PSA is a ratio of the free or unattached PSA to all of the PSA (total) in the blood. This test works inversely. A high number suggests a lower risk of prostate cancer, while a lower number put the patient in a higher risk category. “Free PSA” is the PSA that is floating freely in the blood vs. PSA that is attached to other proteins in the blood.

PSA -3 is a newer test that has been shown to help select which men are at risk of having prostate cancer even though they have had a negative biopsy.

PSA is even more useful as a “tumor marker”. For men who have had treatment of prostate cancer, following their PSA after surgery or radiation is a great way of watching for recurrences. A biochemical failure is when the PSA starts consistently rising after cancer treatment. Fortunately, there are usually many years between a bio-chemical failure and the onset of symptoms from a tumor.

Testis Cancer

This is a cancer of young men. It usually presents in the teenage years, twenties and thirties. It becomes increasingly uncommon in the forties, fifties and later years. Men usually will discover a lump or firm area in the testicle which is not particularly painful. Unfortunately patients don’t always seek medical evaluation very quickly.

There are several types of testis cancer. They are treated with surgery, radiation and chemotherapy depending on the tumor type. Men should do testicular self exam or TSE monthly just like women should do monthly breast exams. Urologists recommend that once a month, say on the first day of each month you should examine the testicles in a warm shower when they are hanging low and easily examined. Watch for lumps or bumps or changes from previous examinations. If you are concerned about any changes you should see your doctor and possibly get an ultrasound examination.

Testosterone Deficiency & Hormone Testing and Treatment

Testosterone Deficiency (TD) is a common problem as men age. It is particularly common in diabetics and the obese. These hormones are well known for their role in maintaining sex drive, male sex characteristics, and erection capabilities. They are also involved in maintaining the blood count, bone density, muscle to fat ratios, energy, and psychological well being.

Testosterone treatment is seldom the single answer to impotence problems, but can be part of an overall program of managing erectile dysfunction problems.

We do detailed testosterone testing, including bio-available testosterone, sex hormone binding globulin, DHEA. We assess symptoms of some of the above conditions and then guide you in managing this important when necessary.

Urinary Tract Infection “UTI”

This is a broad term that covers infections of the entire urinary tract. Other names imply infections of particular areas.

Pyelonephritis Infection of the Kidney

• Ureteritis Infection of the Ureter
• Cystitis Infection of the Bladder
• Epididymitis Infection of the Epididymis
• Prostatitis Infection of the Prostate
• Orchitis Infection of the Testicle
• Urethritis Infection of the Urethra

Sexually Transmitted Diseases “STD” are infections of any of the above organs by organisms or viruses that are passed by sexual contact.

“UTI” can be devastating, life threatening emergencies, a chronic disturbance or completely asymptomatic. We often try to cultures to grow and identify bacteria  to prescribe the correct antibiotic. Some infections and bacteria are treated without culture as we often know the correct antibiotic to use for certain bacteria.

Difficult to treat and resistant bacteria are increasingly common and include MRSA – Methicillin Resistant Staph Aureus, and Vancomycin resistant Enterococcus.

Urodynamics and Uroflow Evaluation

These examinations are used as an aid in the diagnosis and management of urination problems.

Uroflow studies involve voiding into a toilet equipped with a device that measures the rate, duration and volume of urination. This gives the physician a measurable quantification of what happens during the voiding process. Using a bladder scanner afterward to determine the amount of urine remaining in the bladder provides more information.

Urodynamics are a more complex set of tests that provide additional understanding of exactly what is happening with the bladder muscle, prostate and sphincter muscles that are all part of the voiding process. These studies may include cystometrogram, multichannel, or subtracted cystometrogram, uroflowmetry and urethral pressure profile. We have recently acquired a state of the art Mediwatch machine that provides excellent studies!

Varicocoele

Varicocoele refers to abnormally dilated veins that drain the blood from the testicle. The valves in the vein are not formed correctly or breakdown and the vein subsequently enlarges. It has been described as appearing like a bag or worms. Varicocoele usually appear at the time of puberty but may not be noticed until many years later. Varicocoele are generally painless but some men may complain of an ache or heaviness in the testes with prolonged lifting or standing. Varicocoeles can be associated with male infertility and abnormal sperm counts. Ligation (tying off) the dilated veins (called a varicocoelectomy) may help infertility problems and is often considered in younger males with larger varicocoeles. The great majority of varicocoeles are on the left side, however they can be found on both sides or only on the right.